HospitalInspections.org

Based on review of policy and procedure, staff interviews, and review of training documents the hospital failed to provide restraints in a safe and effective manner.

Findings:

1. On 7/20/2010 the surveyors reviewed patient #1's medical record. Documentation at the time the restraint was applied indicates patient was in a prone position on the hallway floor in a "Creating a Positive Environment" CAPE hold for twenty minutes. In an interview with Staff H (CAPE training educator) if a patient went to the floor, the patient was to be moved to a supine position and carried to the observation room to be held in restraints. Staff H also stated there was not a CAPE hold approved for patients on the floor. Staff B did not know of any CAPE holds where patients were placed prone on the floor. On the afternoon of 7/20/2010 in an interview Staff A was not aware of a CAPE hold approved for patients prone on the floor.

2. On 7/20/2010 surveyors reviewed the "restraint and seclusion" policy and procedure and ( CAPE) training and video instruction. None of the documents or the video presented indicated the method described in the patient's record was an approved method for restraining a patient or approved as a CAPE hold.